AccountId: 011433970860
ContactId: 90f6a6cb-7015-4d60-9008-e24dbc86da1f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 482649 ms
Total Talk Time (AGENT): 245153 ms
Total Talk Time (CUSTOMER): 181946 ms
Interruptions: 4
Overall Sentiment: AGENT=0.3, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/07/90f6a6cb-7015-4d60-9008-e24dbc86da1f_20250507T14:04_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Yeah, hi, [PII]. My name is [PII] calling on behalf of dental office to check eligibility and benefits for your patient to turn on a recorded line. Can you please help me with that?
[AGENT][NEUTRAL] Sure, I can verify benefits and eligibility for you. And you say your name is [PII]?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] No, it's [PII]. It's [PII]
[AGENT][NEUTRAL] Oh, [PII], I'm sorry, give me one moment.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Hospital.
[AGENT][NEUTRAL] OK, and [PII], what is that policy number, please?
[CUSTOMER][NEUTRAL] It's 026.
[CUSTOMER][NEUTRAL] 19213.
[AGENT][POSITIVE] OK, thank you so much. And do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] Mhm, yeah, callback number is [PII]. It's a direct line.
[AGENT][POSITIVE] OK, thank you so much, give me one moment.
[CUSTOMER][NEUTRAL] Hello
[AGENT][NEUTRAL] OK, thank you. And [PII] verify the patient's name, date of birth?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] The patient's name is [PII] and date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you, um, and you say you're calling for benefits and eligibility, correct?
[CUSTOMER][NEUTRAL] Mhm. Yeah.
[AGENT][NEUTRAL] OK, I'm showing his effective date is [PII]. He is active on the policy. And now you just need a general breakdown of benefits or I can send you a fax back?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I have a specific questions regarding this patient's policy. I have the group name group number?
[AGENT][NEUTRAL] Uh, sure, let's see. Group number 70044.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] The group name is the Mega 4 staffing group.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Can you please spell that for me?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] The Mega MEGA 4 staffing group.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Perfect. And [PII] runs in the calendar or fiscal.
[AGENT][NEUTRAL] Uh, calendar year.
[CUSTOMER][NEUTRAL] 14. Is there any future termination date?
[AGENT][NEUTRAL] I'm sorry, say again.
[CUSTOMER][NEUTRAL] Yeah, it's only future termination date.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm sorry, the what termination date? Oh, there's no term date. It's just showing the policy is active.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm. Perfect. And could you please verify the network status of the provider, whether he's in or out of network?
[AGENT][NEUTRAL] Uh, we don't have a network with this insured's dental policy is open to where they can go to any dental provider.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Perfect. And have the annual maximum as the detective plus.
[AGENT][NEUTRAL] Uh, not a guarantee of payment, just a verification of coverage. The patient has a benefit max that pays up to $500 per calendar year and he has a $50 deductible that is applied to everything but preventative.
[CUSTOMER][NEUTRAL] I'm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Perfect. And how about the family detectables?
[AGENT][NEUTRAL] Uh, there's not a family deductible since he is the only person on the plan.
[CUSTOMER][NEUTRAL] And you know,
[CUSTOMER][POSITIVE] Perfect. And then nothing used and nothing made in our max and detectives right for this calendar year.
[AGENT][NEUTRAL] Correct. He has no history.
[CUSTOMER][POSITIVE] Perfect. Mhm. on the phone and we're waiting for our missing too close on this policy.
[AGENT][NEUTRAL] Uh, there's some, there is a waiting period, but there is no missing tooth claws.
[CUSTOMER][NEUTRAL] Ok
[CUSTOMER][NEUTRAL] And waiting period is for what, what kind of services.
[AGENT][NEUTRAL] There is no waiting period.
[CUSTOMER][NEUTRAL] Uh-huh. OK. And have the coverage percentage for prevenue basic and nature.
[AGENT][NEUTRAL] Uh, major is not covered for preventative. It pays 100% of UCR. Basic, basic restorative, uh, SMX panoramic pays at 80.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] How about uh endoal simple extraction or surgery?
[AGENT][NEUTRAL] Endoperio, that is an oral surgery are considered major and not covered. Simple extractions, those are considered basic, so it pays at 80% of UCR.
[CUSTOMER][NEUTRAL] Mhm. And how about anesthesia?
[AGENT][NEUTRAL] Not covered, that is considered major.
[CUSTOMER][POSITIVE] Mhm. Perfect. And then I have some goals to check. I just need the percentage and frequency. Can you please help me with that?
[AGENT][NEUTRAL] Are they any of those clothes for major or they preventive and base or preventive and basic?
[CUSTOMER][NEUTRAL] Center preventive and basic.
[AGENT][NEUTRAL] OK, what are the codes?
[CUSTOMER][NEUTRAL] Mhm. Yeah, 01200274.
[CUSTOMER][NEUTRAL] 11
[CUSTOMER][NEUTRAL] 0 to 10.
[CUSTOMER][NEUTRAL] 1206.
[CUSTOMER][NEUTRAL] 1351.
[CUSTOMER][NEUTRAL] 23914341
[CUSTOMER][NEUTRAL] 4910.
[CUSTOMER][NEUTRAL] 4355.
[CUSTOMER][NEUTRAL] And 4346.
[CUSTOMER][NEUTRAL] Oh I'm on my
[AGENT][NEUTRAL] OK, exams, the 120 are uh fall under preventive pace at 80% I'm sorry, at 100% of UCR and exams are 2 for 12 month period.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] The 274 bite wings are once every 12 months, they fall on a preventative.
[AGENT][NEUTRAL] Cleaning, so 1, 1110 is once every 6 months.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] The 2:10, what is that for? Is that for?
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] One moment
[CUSTOMER][NEUTRAL] Come on.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Uh, for a full
[AGENT][NEGATIVE] Full mouth that falls under basic and it's once every 5 years and it does share a frequency with the panel. Uh, for the 1206 is not covered, well, uh, fluoride is under the age of [PII], once every 12 months. The 1351.
[AGENT][NEUTRAL] The sealants are under the age of [PII], once every 3 years, permanent molars only, and for the last cos the 4311, I'm sorry 43 41 49 1043 55, 4346 are not covered since they are major services.
[CUSTOMER][NEUTRAL] Look at
[CUSTOMER][NEUTRAL] Mhm. How about 2391?
[AGENT][NEUTRAL] Oh, I forgot that one. I'm sorry, 2391. Give me one moment.
[AGENT][NEUTRAL] It
[AGENT][NEGATIVE] Uh, fillings are once every 2 years, and they fall on our basics at pace of 80.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] If you can you please repeat the frequency for uh C 13, I'm sorry, fluoride 1206.
[AGENT][NEUTRAL] Fluoride is under the age of [PII], once every 12 months, and they are considered preventative.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm. Perfect. And orthodontic is not go right under this policy?
[AGENT][NEUTRAL] Correct. Like I said, um, major services are not covered.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Perfect. And there's no tooth is free for this patient?
[AGENT][NEUTRAL] Correct, there's no history.
[CUSTOMER][NEUTRAL] Mhm. I have to pay already as well as the claim's mailing address.
[AGENT][NEUTRAL] Uh, mailing address is [PII].
[AGENT][NEUTRAL] And the payer ID is 60801.
[CUSTOMER][POSITIVE] Perfect. OK, and then can I get the call reference number?
[AGENT][NEUTRAL] Uh, we don't give reference numbers, but if you like, you may use my name in today's date. And is there anything else, [PII], I can assist you with today?
[CUSTOMER][POSITIVE] Mhm perfect.
[CUSTOMER][POSITIVE] I'm done with my questions. Thank you so much for the information provided. Have a wonderful rest of your day. Take care. Bye for now.
[AGENT][POSITIVE] You're welcome. Thank you for calling APL. Have a great day.